We have attempted to highlight aspects of transoral procedures that we have acquired by experience in 235 cases and review the necessary applied surgical anatomy as well as some aspects of surgical pathology that are either not available or appropriately emphasised in the standard texts. Some previously unpublished conclusions drawn from our work have been made, but technical details of procedures available in published work have been excluded. We consider such surgery the route of choice in all midline extradural, clival, craniocervical junction, and upper cervical spine pathology, and it may also be used for some intradural pathology. All of this requires teamwork and experience; it is not an area for the occasional operator. Having said that, however, we believe that there is still a great deal of pathology not yet referred that would benefit by this type of surgery.